Diseases Of The Nose Throat And Ear

58 THE NOSE AND PARANASAL SINUSES

patients. Polypi, however, rarely disappear without surgical removal. Eacl
case must be judged on its merits. There is no justification for removing smal
nasal polypi which are discovered incidentally or which give rise to nc
symptoms. In such cases conservative treatment is ordered and the patienl
examined at intervals because growth is generally slow. Nasal polypi which
are causing nasal obstruction should be removed together with the small area
of bone at their point of emergence.

The surgical removal of a single pedunculated polypus may be accomplished
under local anaesthesia with a suitable snare which is closed as close as
possible to the point at which the polypus emerges from the ethmoidal cells.
The removal of multiple polypi is usually performed under general endo-
tracheal anaesthesia, the endotracheal tube being packed off to prevent the
entry of blood into the trachea and bronchi. The nose is usually packed or
otherwise anaesthetized preoperatively with cocaine hydrochloride and
adrenaline hydrochloride to reduce bleeding which is often brisk. In many
instances this preoperative treatment shrinks the nasal polypi, especially the
allergic polypi, so that small growths may disappear from sight, only to
reappear when the vasoconstriction has worn off. Multiple polypi are removed
with the snare and with forceps, and the affected ethmoidal cells are opened up
in the hope of minimizing the chance of recurrence. If haemorrhage is brisk
a pack of ribbon gauze is left in the nasal cavity and removed when the patient
is conscious and can be propped up. After-treatment consists of steam
inhalations. Vigorous nose blowing should be forbidden as this may restart
the bleeding. The patient is kept in hospital for 48 hours and will be off work
for a week.

Recurrences of nasal polypi are common, especially in allergic patients who
may be subjected to repeated removals. This is partly due to the preoperative
shrinkage and partly to the continuing allergic state. In order to diminish the
frequency of recurrence it is possible in some patients to operate under
hypotension without any preoperative cocainization, and in this way small
polypi may be removed under vision.

Some surgeons advocate a short course of corticosteroids following removal
of allergic polypi. A suitable routine is to prescribe betamethasone (Betnesol)
tablets, giving 0-5 mg thrice daily for 3 days; 0-25 mg thrice daily for 3 days;
0-25 mg twice daily for 3 days and 0-25 mg daily for 3 days. This is followed
immediately by a course of one of the antihistamines. Other surgeons
prefer to give an injection of 80 mg of methylprednisolone (Depo-Medrone)
continuing this at intervals of 3 months or longer, depending upon the
response.

Radical external ethmoidal surgery may be required for frequent recurrences
of nasal polypi when simple methods have failed, and the results are
encouraging.

NASO-ANTRAL (CHOANAL) POLYPUS

The naso-antral polypus arises from the mucous membrane of the maxillary
sinus. The morbid condition of the antrum is probably catarrhal, and as the
swelling increases a small polypus develops in the region of the accessory
ostium of the sinus. The polypus protrudes into the nasal cavity through the
accessory ostium, which is situated posterior to the normal orifice. It increases